National Assembly for Wales

Good afternoon, everyone. Can I welcome Members to this virtual meeting of the Children, Young People and Education Committee? In accordance with Standing Order 34.19, I've determined that the public are excluded from the committee's meeting, in order to protect public health. In accordance with Standing Order 34.21, notes of this decision were included in the agenda for the meeting, which was published last Friday. The meeting is, however, being broadcast live on Senedd.tv, with all participants joining via video conference. A record of proceedings will be provided as usual.

Aside from the procedural adaptation relating to conducting proceedings remotely, all other Standing Order requirements of committees remain in place. The meeting is bilingual, and simultaneous translation from Welsh to English is available. If we become aware that there is an issue with the translation, I will ask you to pause for a moment while our technicians reset the system.

Can I ask Members if there are any declarations of interest, please? No. Okay, thank you. I'd like to note as well that apologies have been received from Hefin David AM, and welcome Jayne Bryant AM, who is substituting for Hefin this afternoon—welcome, Jayne. Can I also note for the record that, if, for any reason, I drop out of the meeting, as previously agreed by the committee, Dawn Bowden AM will act as temporary Chair while I try to rejoin?

Moving on then to item 2 this afternoon, which is an evidence session on the impact of COVID-19 on the physical and mental health of children and young people with nursing, paediatric and general practitioner representatives. I'm very pleased to welcome Dr David Tuthill, officer for Wales for the Royal College of Paediatrics and Child Health; Lisa Turnbull, policy and public affairs adviser at the Royal College of Nursing; Sian Thomas, consultant nurse in child health and Royal College of Nursing member; and Dr Mair Hopkin, Royal College of General Practitioners. Thank you, all, for joining us this afternoon. We've got lots to cover, so we'll go straight to questions, and the first ones are from Siân Gwenllian. Siân.

David.

Thank you very much for having us. I think perhaps I could help answer the committee's questions here. Children are probably unlikely to be directly affected by the virus with physical illness—that's uncommon in terms of severe illness, but as an inflammatory condition, which we see, but it's very uncommon. What they have been affected by quite greatly is, if I could call it, collateral damage—their schools have been closed, their clubs have been shut, they can't socialise. All those things have affected children, and they're very anxious, because there's a lot of worry about coronavirus, which they're hearing about—their grandparents might have died, or they're hearing that thousands of people have died.

I think there might have been two children's deaths in the entire UK. But children have been affected by the collateral damage, rather than the direct damage of COVID. The royal college is doing surveillance studies to try and answer and get some more information about it. We're looking at the neonatal transmission, and I think that's probably small. We're looking at delayed presentations and I think you've got some questions on that later, and I'll address those then. And also, the rate of hyperinflammation in this new syndrome that has come out as like a Kawasaki-type of illness. For the panel, that's an illness that has been uncommon, but where the body immune system probably overreacts after having a stimulus. Chair, does that answer the panel's question on that?

Thank you. Siân.

Thank you. I think whereas I can be certain on the answer to the first part of your question, I think one has to be cautious here in terms of the evidence is evolving, and in the UK, the numbers of screening, the background tests, the demographics of children and how—[Inaudible.]— infected is still going on. I think I would summarise it that children are probably less infectious and probably spread it less than adults, but I would please attach some caution to that, as I think further evidence is really required. Whereas I can be certain about the first bit of my evidence, I think the scientific evidence at the moment on this path, the infectivity is less clear. On balance, the evidence—as I say, at the moment, I think they're probably less infective.  

Who'd like to start? Mair, and then Lisa. 

Yes, I'm happy to start with that. Yes, I think it's been documented that the clinical medical officer would have hoped that we could have delayed the start a little longer and adjusted the term times. And the reason for that is because we know that the infectivity is predicted to go down with time. And whereas at 1 June, it was something like 1.74 per cent risk of children passing on COVID to adults, that had gone down to under 1 by the middle of June, and would go down to well under 1 by the beginning of September. So, it's a balance, really, between getting the least infectivity for teachers and other school pupils against the harms that we believe are being done by children being isolated, not having the social contact that they usually have in school.

We worry about health inequalities, because some pupils who are in deprived backgrounds will not have the opportunities and will find that they're slipping further and further back in terms of catching up with their peers educationally. We worry about children being hidden at home; that they have little contact with adults, and so, we may well be missing the effects of child abuse, and we may well be missing neglect, poor nutrition and anxiety in children. And the longer, I think, that they're away from school, I think the more anxious and the more parental separation anxiety there will be when children do eventually go back. 

Thank you. Lisa, you wanted to come in.

Yes, thank you. I think our concerns in the royal college have been around making sure that the workforce is ready to receive children going back into the system. So, that would be health visitors, school nursing, looked-after children nursing, the safeguarding systems. So, what we're concerned about is that all that workforce is back where it should be; that the need for risk assessments and PPE of those employees has been considered, and if there's a need to change methods of working, that that has already been considered and those processes are in place, to make sure that children and young people still have access to those range of services that they should. 

So, our concerns are focused on the physical health, so that could be around the restarting of the usual checks or immunisation programmes, opportunities for exercise, opportunities for that kind of physical activity—that that support is there. I know that my colleague, Sian, might want to say something specific about children who have chronic conditions as well. But, in terms of mental health and well-being, we're also aware that there should be extra support for children and young people, and for the professionals who are dealing with children and young people, and that could be in the manner of online resources or podcasts to deal with anxiety, to deal with those kinds of well-being issues, and where there's been bereavement, to specifically deal with those types of issues as well. 

So, safeguarding is absolutely critical, as has been mentioned before, to make sure that those systems are up to capacity. So, it's kind of—. Our concern is that all of these factors have been planned for in preparation for the resumption of the education system. Because if issues are picked up in children and young people, there needs to be somewhere that can receive and deal with those issues. 

Okay, thank you. And, David, you wanted to come in. We've got questions later on specific groups of children. David, did you want to come in?

Thank you very much. I think royal college has issued a statement on that, but there's been quite a polarised debate about it, and we look to a common ground. But whatever time the schools open there's going to be a balance, as Mair was alluding to, between balancing priorities with opening schools to help the mental health and well-being of children with the small risk of transmission. Whatever rate it is, there's always going to be a balance until either we're coronavirus-free, and I think that might be unlikely, or we have vaccinations. We do not know if a vaccination will work; there's not one there that's near at the moment. We don't know if we're going to be protected if we've had it before. There's a lot of uncertainty. We may be in this situation for up to two or three years, possibly. I think it's very unlikely to be a quick answer that we will have.

So, we need to plan. I think there is a protective effect of schools for children. Taking into account all that Lisa said as well—that we need services to support them when they go back to school. I think there's going to be a balancing act, but certainly, safeguarding services there ready for children if referrals happen, but one of the concerns we have, as a college, is that safeguarding referrals have dropped considerably over the last 12 weeks that we've been in lockdown. 

I am not a public health expert; I'm a paediatrician. I know that children are suffering from not going to school and children are suffering, not directly from coronavirus, but from these collateral effects. If you ask specifically, from a child's point of view, restarting school is a really good idea. But there's a much wider perspective here, as the other participants have alluded to, about the not wanting to transmit it to teachers, especially elderly teachers, and we're not wanting to get a resurgence of the coronavirus in the community. That's going to have to be balanced by the public health evidence.

The college wants there to be a sort of track and trace element; it wants the services to be there to support and so we can identify cases so they can be handled carefully and isolated for the two weeks or two and a half weeks, whichever is necessary. I think the exact date of it is going to be, not an arbitrary call, a balance between the risks, and yet, I think a public health expert would give you better advice. But, purely from a children's point of view, opening schools is a good idea, but there are all the wider characteristics, as Lisa and Mair alluded to.  

Yes, I do, totally. When I was—I can speak from my own experience and the national experience. When I was on the week before Easter, which was when—[Inaudible.]—only had four cases of coronavirus in the children's hospital; all of whom were mildly affected. There are a small number of children who have these HIMS conditions—hyperinflammatory condition. I think we may have got up to 10 in Wales, the whole of Wales, over this time. That's quite a small number, compared to what, 600,000 children we've got. So, children have not been greatly affected. I think that maybe one child has gone up to the higher dependency unit. To the best of my knowledge, I don't think we've had any or just one intensive treatment unit case, so the in-patient facility for children was condensed into a lower footprint to make room for adult patients in the children's hospital, but I don't think it was ever needed in the end.  

Okay. Mair, briefly. 

Yes, I was just going to say, we don't know what this virus is going to behave like. We think there may be a second wave in the autumn and what we'll need to think about very carefully is the effect that going to school and then not going to school and then having to reintroduce back is going to have on children as well.

Okay. Thank you. Siân, are you finished now? 

Yes. 

Can I move on to Suzy Davies?

Thank you, Chair. We've covered quite a lot of what I wanted to ask already, but I wouldn't mind just zooming in, with Sian, I think, probably, on those particular groups of children who might be disproportionately affected by lockdown, either because of their specific physical condition or because of being neuroatypical or having mental health problems. And I wonder if you can just—. Perhaps if you can address that first group of people with particular physical vulnerabilities and what the effect has been on them.

Well, that group of children are supported in the home and in schools by community children's nurses and what we've learned since the beginning of the COVID experience is that parents are really, really anxious. Even though they have community children's nursing supporting them in the home, they've chosen not to have the nurse to support them, because they didn't want transmission—any contact, really; minimising the contact. But families are now—having given advice to the families in relation to the spread of infection, and with adequate PPE, the community children's nurses are supporting children in the home. But, obviously, there's a different level of anxiety with reintroducing them to school. And also some of the interventions and therapeutic interventions for this group of children have been paused, and, therefore, there's a lot of stress on the family to deliver all of the support by themselves. So, it's a balancing act: we're advising families that we're there to support them, but there's obviously a choice for the families about what they want the children to be allowed to do.

So, in terms of there being enough community nurses, that's less of an issue than parental confidence, or is it a question that both are an issue? Has parental confidence got better, for example?

Well, the confidence has got better, yes, because it's about all of us, all of the health boards in Wales and in the UK, advising families that we're still there, open for business to offer support and advice to families. They chose not to present themselves to secondary care because of concerns, so it's about that messaging to families that we're still here for them, that the community children's nurses are available to support, and they still go into the schools and will be going into the schools to support when schools reopen, including special schools. 

Okay. So—

Lisa, you wanted to come in.

Oh, sorry.

Yes, thank you. Thank you very much, Chair. I wanted to make a point about the capacity of the system and where investment could be made now to really actually make a difference and support the situation going forward. There is a shortage of children's nurses full stop in Wales, and there is a shortage of children's nurses in the community specifically, and we do need to increase those numbers. I would say that Health Education and Improvement Wales is currently considering the commissioning figures for next year. We have written to them to say that this is an area that they need to think about urgently now, because, as Siân Gwenllian quite rightly said, this is about a situation that is going to be ongoing; we're going to be living with this situation for some time to come. So, if you think about three years from now, when those nurses would graduate, that is the workforce that we're looking at.

The other point I wanted to make is around IT technology. There were some excellent moves and investment, for example, with—. We saw GPs moving very swiftly, actually, and successfully, over to doing much more phone calls, doing more video calls, to be able to work in these new ways, which, actually, were helped. Now, community nursing and school nursing are actually behind the curve in terms of that access to technology. They very often don't have these kinds of mobile devices. So, if we're talking about how we're going to support the routine business of providing healthcare to children and young people going forward, we need to think about what technology is actually needed to support those new ways of working so they can provide that kind of advice and education that they would normally perhaps have done by going in in a face-to-face manner, and finding a new way of doing that. So, there is something there about actually taking that investment and putting it in now in things that can make a huge difference for years to come.

Well, actually, could I ask you, then—there'll be questions about mental health and well-being from somebody else later on, but for those people who have neurodevelopmental conditions or learning difficulties, will this emphasis on IT, basically, and digital solutions, be of good use there, or is it going to throw up problems of its own if some of those individuals can't actually have face-to-face meetings?

Well, obviously, that would be dependent very much on the individual and what their needs were, but there are ways in which technology can be very beneficial, and, equally, it might not be suitable for all cases, but if we're talking about, say, something like provision of general advice, there's a lot of evidence to show that, for example, when you're dealing with, say, issues around mild anxiety, around depression, around those kind of areas, that there's a lot that can be done, actually, through online and through podcast support that can actually be equally as effective.

Okay. Well, maybe we'll get a chance to explore that later. Just a final question from me, Chair, on those who have atypical neurodevelopment, or have learning difficulties, about whether their experience of lockdown is acutely different in those situations where perhaps you've got very busy households, or access to computers might be difficult because mum or dad is working at home and using the computer. Have you got any sort of specific evidence that that experience for that cohort of children has been particularly frustrating, for want of a better word?

Who would like to take that one? David?

I can give you, I suppose, some practical examples of where children with neurodisability have got some problems. Children, say, who are deaf and might lipread, at the moment, with the wearing of masks, going in to communicate—. I've tried to do my clinics at the moment digitally, as Lisa was alluding to that GPs have done, by telephone or video links, with moderate success, but there are some things you've still got to bring children in for, and, speaking through a mask or with a visor over, it's actually quite difficult to hear people. I've just done a clinic this morning with some nurses who were doing skin retests, and even though I've been working with them for the last 15 years I found it—I had to really, really listen and get almost closer than I would want to hear them. Visual ones—people who are deaf, that's just a particular example. I think children who have got neurodisabilities have a hard time anyway; the fact that the schools aren't there—it's this collateral damage that we're talking about, and inhibitions to the cues that we normally use are going to be a problem.

Okay. Thank you very much. And I'm guessing you're all happy with the guidance that's gone out and parental response to that. Maybe that will come up with other questions. So, thank you, Chair.

Okay, thank you. So, as a committee, we're fully committed to putting children and young people and their voices at the heart of everything we do, so we've been asking young people for questions that we can put to witnesses, so I'd like to put a couple of those to you now, if that's okay.

The first is, 'I can't go out as often as I would like during lockdown. Will there be help for me to get back to full physical health?' Mair, then Lisa.

I'm not aware of any specific programmes and I think that this is probably something that would start to happen when children return to school. I think that's probably the best delivery, rather than through general practice.

Lisa.

I think this is really important, and I think that's what I was slightly alluding to earlier—I think all kinds of professionals are going to need help thinking through how to do things differently. So, I know, for example, in all of the different sports that guidance has been issued as to how we can move away from, say, traditional contact sport, like football or whatever, to, say, something that can be actually training activities and physical activities that can be done while maintaining social distancing, and I think there are other areas that can be—. This could be an opportunity, with an effort, to look at, for example, cycling or walking to school, that kind of thing. So, I think it's a really important point, because there is no doubt that physical activity has taken a hit because of the lockdown situation, so I think putting effort into making sure that those levels go up will be really important, because we know those levels are low in Wales anyway. So, putting effort into that and making sure that the teachers, that school nurses, that everybody has access to that kind of best practice and advice and examples is the really important thing, because otherwise individuals are going to be struggling with how to deal with this by themselves. And, again, essentially, we'd be trying to reinvent the wheel, and that would slow everything up. Because the knee-jerk action, obviously, is a protective one, is to say, 'Right, we're not going to do that, because—.' You know, 'We're not going to play football, so we'll just cancel that.' Well, obviously, we need to do something as an example instead of that.

Okay, thank you. David, was that—are you indicating?

Yes, it was just—. Chair, thank you. Just one other aspect of this that I don't think has yet come up is that the shielding advice that's been given out is predominately adult-based, and for many, many children, it's been completely inappropriate. I did raise this with Frank Atherton a while ago, and with John Williams as well in Welsh Government, saying, 'Look, we need to have age-appropriate shielding advice. The things you're shielding adults for—all very appropriate—they're just inappropriate for children. And that has resulted in some children unnecessarily being shut down.' The college again has put a statement about this, that, unless you're under a hospital consultant—we could not see any reason for a child to be shielded who isn't under the care of a hospital consultant. 

Okay, thank you. That's a very important point, I think. And the second question from me, then, from a young person is: 'Why have they closed exercise parks? Don't they realise that physical health, physical exercise, helps our mental health?' Who'd like to take that one? Mair.

Yes, I think the reason for closing the parks was because of the social distancing, and the difficulty with maintaining social distancing in park areas. I don't know when it will be safe to open the parks again. I think it's, again—probably it is disadvantaged children who have a further disadvantage in that they probably only have access to a park, and may not have access to a large, green area where they can have a run around with a ball, or a large garden where they can play outside. 

Okay, thank you. Lisa.

Just to add, really, to that point, there's something about us getting used to this new way of life—if that's going to the park and understanding social distancing, and it's going to the park and wearing a mask, then that's what we need to do. But there's also something about us recognising that when we see other people in that space—about how we react to that. So, you know, you see a park with people in it and, you know—and certainly my instinct is, 'Oh gosh, you know, that's frightening.' But, actually, if you stop for five seconds and look around, you can actually see that everybody is exercising while also maintaining social distancing. I think it's the same if you see groups of young people or children and they're out and about, they're enjoying themselves or they're socialising. Then we need to not react to that with some kind of—as a society, as adults, we can't react to that with fear. That's a positive thing, that young people are out socialising and enjoying the space. We need to get back to that mentality of recognising how that can be done safely.

Okay, thank you. David, very briefly.

It was really just to, I think, emphasise what Lisa was just saying there, actually, about how do we make spaces safe. I think we want to open up parks and we should give attention to how we do that in order to utilise the parks for their good beneficial effect, rather than just closing them. I think it's a really good question that your young person has asked—a fantastic question.

Thank you. The next questions are from Jayne Bryant.

Thank you, Chair. What impact has the pandemic had on the children's healthcare workforce? I know, in my own area, the families and therapies division at Aneurin Bevan University Health Board have talked about extensive redeployment of staff and high sickness levels. To what extent has that been seen across Wales?

David, then Lisa. I am going to have to ask for concise answers, though, just because of the time constraints. David.

Okay. We've had paediatric staff deployed out of area—particularly community staff into acute care paediatricians, the junior staff out into the adult workforce. Most of them are coming back is my understanding. I'll leave Lisa to speak about the nursing implications.

Lisa, thank you.

Yes, there have been, and we feel it's now time that they need to be brought back, and, if other areas are then lacking, we are fortunate in that because of the volunteer work of, say, student nurses and so forth, we do have other workforce to draw on. So, what we're saying is: if they are children specialist, they now need to go back to where they were, and then bring in more people if necessary. And I also refer to my earlier point about the commissioning process—we need to look at that now.

Okay. Mair.

GPs have not been redeployed, but we've lost our health visitors, and that has led in some areas of Wales to a 10-day delay. The health visitors are having to do remote consultations with parents, which has left a lot of new parents really bereft of any support. They haven't had their family around; they haven't had contact with their friends; and, more importantly, they haven't had contact with the health visitor.

Okay. Jayne.

Thank you, Chair. Sian mentioned earlier—or touched on this—that services are open for business and trying to encourage more people to attend. Do you think that more needs to be done to encourage people to engage—and families to engage—with services? What sort of decline have you seen in routine vaccinations, among services like that?

Who would like to take that? Mair?

Yes. I've asked locally, and the immunisation rates are up. I've asked the clinical medical officer and he was unable to give me any figures across Wales. Certainly, initially, parents were a little bit anxious about taking their children to be immunised, so I wouldn't like to speak for the whole of Wales. But, certainly, my part of south-east Wales seems to be fine with immunisations.

In terms of access, we know that fewer people have accessed care. Even though general practice has been open, there has been a perception that it is not safe to come to the surgery, or that you can't come to the surgery. For safety's sake, most practices now offer a telephone triage first.

When I was in practice myself, I worked very hard to have open access for children so that they would feel comfortable about coming to the surgery themselves to talk about anything that was important for them. With telephone triage and then remote consultations, children are often consulting when adults are in the room with them. I'm very aware that general practice is less accessible for children, which is why I think that it's really important that we have robust services available in school for them.

Thank you. David.

We're collecting data on delayed presentations. I think that, so far around Wales, we've had about 40 cases where children have been delayed because parents were worried about other things such as a severe case of diabetes and other things. The royal college is collecting these data nationally as well. I can't give you any more specifics than that.

We saw about, I would say, a half to a two-thirds drop in the number of referrals acutely. Some of that is good because some of them were the worried well that didn't need to be seen. But, in amongst that were some cases that we had, where the royal college had a campaign to inform parents—in fact, we ran it on BBC News in Wales and also the UK, Radio 4, and there was the social media campaign—deliberately to try and reassure parents that we were there for children. It was, 'If your child needs the hospital, come into hospital. We're there for you and we'll make it safe.' 

Thank you. Sian, you indicated, I think.

Yes. As to the previous speakers, we are using all social media platforms to get the information out. A recent consultation with young people said that they want short bursts of information regularly from us, but they are using our social media platforms for those purposes. So, that was good to hear.

Okay, thank you. Have you finished, Jayne?

Yes. Thank you, Chair.

Thank you. The next questions are on new ways of working, from Janet Finch-Saunders.

Good afternoon. More services are being delivered remotely and face-to-face appointments are significantly reduced. We know that around 13 per cent of households in Wales have no access to the internet. So, how effectively are remote services operating across Wales?

Who'd like to start on that one? Mair?

Yes. Most general practice is happening remotely now. Hopefully, there will be a redress of the balance between face to face and remote. But, I think that the days of people just turning up at the surgery, either asking for an appointment across the desk or expecting to be seen, are far away because of the need to socially distance and protect patients in the waiting room. So, we can't just have open access.

When I asked pupils what they wanted years ago, secondary school pupils wanted a drop-in GP available whenever they turned up, and that's just not going to be possible. But, what we can perhaps do is be more accessible to them on their iPhone. But, I do worry about pupils, or children, who haven't got access to IT and children who are afraid to use their IT because they are monitored.

Okay, thank you. Sian, had you indicated then that you wanted to come in?

Yes, please. Just picking up on that point, and I think that Lisa mentioned it earlier: it's important to have that virtual access for patients and staff. Not all of the staff have got technology-enabled access. So, there's more work to be done on that, and to be able to offer children the choice of which version they prefer. Some prefer the face-to-face contact still, so it's about having the options for the future.

How concerned are witnesses, then, that some children's health needs may not be identified, and also that opportunities to identify and protect vulnerable children may be missed?

Mair, then Lisa, and then David, and I'm going to have to implore you to be as concise as possible, please.

Okay. RCGP has provided a lot of training advice on remote consultations and being aware of domestic violence and being aware of children who are at risk who may not be able to tell you because somebody else is in the room with them. That's really, really important.

Okay. Lisa.

Thank you. We are worried. We think things are being missed. One of the opportunities that really opening the school system provides is that those opportunities will perhaps come back. That's why we're saying the system needs to be up and ready to provide that kind of support. 

The other point I'd make is that routine inspections of care settings have been halted during the pandemic. We actually believe they need to be restarted now, albeit potentially in a different way, but we need the assurance that the quality of these services is there. So, we are calling for, not just children's services and older people's services, but all of the routine work of inspection and quality assurance to be restarted.

Thank you. Janet.

I thought David was coming in.

Oh, sorry. David.

It was only really to say that I think your concern about the safeguarding issues is well made, and there's also been a significant drop in them across Wales: some units have been having only a third of referrals, just to begin to put some figures as a rough estimate for you.

Will the different ways of working and greater use of technology we've seen during the pandemic affect how children's health services are delivered in the future, and what advantages could this have for patients and, indeed, for the services? I think Mair touched on it earlier, and Sian.

Lisa.

It's about the investment in that technology, and we're in a situation at the moment where community nurses and the school nurses are quite often the very last service that technology filters down to. We know some of our members don't have access to e-mail or mobile devices, let alone the opportunity to do video-conferencing and deliver things online. So, there does need to be a clear schedule, if you like, of when some of the really valuable connections that we've seen the IT programme in Wales deliver for other areas like GPs, like pharmacy—we need some of that for community nursing. That needs to be next in order to—. This whole new way of working will continue for the future, for the next 10 years.

Thank you. Mair.

It's important that we look outside health. Not everybody's got good access to broadband, and that may be with or without deprivation. Not everybody's got access to IT hardware that they can use. I think it's really important that, when we're thinking about children going back to school, one of the things we look at is their IT literacy, because if they're not literate then they can't access IT and then they can't access health services. 

Thank you. Just before we move on to the final set of questions, can I just ask Lisa, in terms of the child health programme—you've talked about safeguarding, but it's also about supporting families, isn't it, at a really vulnerable time—as far as you're aware, are all families getting their schedule of visits according to the Healthy Child Wales schedule?

For a detailed answer, I'd have to come back to you, Chair. I wouldn't want to mislead you. I think my impression is similar to what was described earlier, that because of the redeployment in some areas, and also because the routine ways of working have simply stopped rather than being replaced, there have been delays. But I'd have to come back to you. I'm happy to provide that information to the committee separately.

Thank you. That would be really helpful. Thank you. Final set of questions, then, are from Dawn Bowden.

Thank you, Chair. I just wanted to think beyond the current lockdown restrictions and once we get past this and we're starting to see normal services resume. What do you think—all of you—the pressure points are likely to be in terms of health services for children and young people?

David.

I think there'd be a variety of different things. So, in general paediatrics, we've managed to keep our clinics going virtually, even by phone, and there's been a number of children we've had to bring in. For some of them, such as gastroenterology, I think there's going to be a big backlog because they haven't been able to see them so much. The endoscopies have been delayed, the imaging is delayed, and they can't do the number because of the distancing of procedures, so they'll only probably do half to maybe two thirds of the ones they could do before. So, what was already a problem with the service, there's going to be a bigger problem there.

Neurodisability and where staff are being redeployed there, I think there's been a bigger backlog that's occurred there because those staff have been doing other things on top of an area that already had a big waiting list. So, I think it's going to be that different areas will have different challenges. But I think with a backlog that an increase in capacity in some areas will begin to be wanted. And also, the support services, vis-a-vis radiology, histology, and those who want to see tertiary specialist services, I think we may need to look at. Because we've got a period of probably, as I say, maybe two or three years, perhaps it will be less—that would be great news, wouldn't it— where we will have these problems to get over.

Okay.

The good news, I think, is the remote access, because we've equalised it out across Wales far better and it's forced IT services to try and modernise more quickly than we've had for the last 10 years in the NHS. [Inaudible.]

Lisa, you wanted to come in, and then Mair, or have I got that the wrong way around?

That's fine.

Yes. I mean, I think the support for emotional well-being is critical, and I think this committee's made really important recommendations on that in the past, and I think it's important we don't lose traction on those. But just to mention two areas that we haven't previously: one is the test and trace regime for professionals in the education sector. I think it's going to be important to start being able to scrutinise the figures on that, but also to have clear guidance. So, for example, if a professional is identified, are we talking about taking the whole of that team up for consistency? So, what impact would that have? So, we need to have that kind of thinking and that resilience built in now rather than six months down the line.

And the other area I'd just like to flag that we haven't mentioned before—. Because I know the community has included in its broad remit, when it was asking for evidence, up to higher education, and I think there is an important point about young people thinking about going to university in the future, and also the ones currently at university, and the huge, huge changes that have impacted on them. And I think there's a lot of thinking to be done about how we support that and we don't lose, if you like, a generation from that higher education experience. So, we have put some written evidence together; we've made a number of comments on that in our written evidence for the committee. But those are just two areas, I think, for the future that are worth thinking about that we haven't previously discussed.

Thank you. Mair.

Yes. As GP workload picks up, because we know that it dropped in the beginning of the pandemic because people were afraid to contact services, but as the workload ramps up, then our ability to see people safely in surgery, face to face, will be reduced because we'll have to clean in between patients and take care with PPE.

The things that really worry me are neurodevelopmental disorders that children will have developed—things that haven't been picked up routinely, and because we're not seeing the children so often, these things will become more entrenched, more ingrained. As with mental health issues, children are likely to be greatly more anxious than if they'd come to see us early on in their illness.

One of the areas that we haven't touched on today is sexual health and family planning, and the ability of young people to access safe sexual health and safe family planning.

Thank you. Dawn.

Yes. Sorry, I wasn't sure whether Sian was coming in then. So, my final question, really, to all of you, I guess, is: what would be your key recommendations? If you got the opportunity to say to Welsh Government, 'Well, this is what we think needs to happen to protect children and young people's mental health and well-being as we come out the other side of this pandemic', what would be the key recommendations that you would want to put to Welsh Government?

Can I go to you first, Sian?

Yes. I think the information for young people directly, actually. Clear information on guidance and where they can access the resources to support would be valuable, as well as—. That would come from the health boards, but, yes, clear information.

Thank you. Who else would like to comment? Mair and then Lisa.

I think the ability for every child to be IT literate and have access to good broadband and to IT equipment so that they can access these services that are available for them.

Thank you. Lisa.

Commissioning figures are being discussed as we speak. As well as places for adult student nurses, we need critically to increase the number of children's nurses, learning disability nurses and in mental health, because if we have that capacity in the system, then those are the people that will be providing the support to the children and young people—those three groups.

Thank you. The final word to you, then, David.

I suppose we need to think about resilience in the future for the service—that, when this might happen again, how do we protect children? I think Mair's allusion to education and equalising when they're using digital support, not just for health needs, but for educational needs, that can level out some things across Wales. We've got an opportunity to do that; I'm not sure we're taking it at the moment.

Okay, thank you. Thank you, Chair.

Thank you very much. We have come to the end of our time, but can I thank you all on behalf of the committee? That has been a fascinating session that has given us lots to think about and discuss, about how we go forward. As usual, you will receive a transcript following the meeting to check for accuracy. Thank you again for giving us your time this afternoon to discuss these very important issues. Diolch yn fawr.

Thank you. Diolch.

Item 3, then, is a motion under Standing Order 17.42 to resolve to exclude the public for item 4. Are Members content with that? Okay, thank you, and we'll now proceed in private.

Okay, can I welcome Members back to the Children, Young People and Education Committee? Item 5 today is a further evidence session on the impact of COVID-19 on the mental and physical health of children and young people in Wales. It's an evidence session with the third sector representatives. I'm delighted to welcome Simon Jones, head of policy and influencing at Mind Cymru; Kate Heneghan, head of Papyrus in Wales; Sarah Stone, executive director for Wales at Samaritans Cymru; and Stephanie Hoffman, head of social action at Meic Cymru. Thank you, all of you, for giving us your time this afternoon. We've got lots to cover, so we'll go straight into questions from Dawn Bowden.

Thank you, Chair, and welcome, everybody. Nice to see you all. 

Many of the feelings that young people have been experiencing at the moment, such as anxiety and stress and similar kind of symptoms, a lot of people would just put those down to the normal, healthy response to coronavirus rather than them being a mental health problem. Do you think there's a need for clearer messaging about that, to make sure that the right sort of help is available? 

Who'd like to start? Sarah?

Okay, thank you. Can you hear me?

Yes. 

It's a great question, and it's something that we've been concerned about, really. What we don't want to do is to medicalise a perfectly reasonable, natural response to the challenges that young people are experiencing, including the loneliness that we know is quite a significant part of it, and they're going to be impacted by the situation of their parents and their wider family, of course. So, I think it's a very important message, and I don't think it's clear enough, really, that actually the measure of the distress people are feeling shouldn't just be measured through how many young people tip into mental health problems that are defined as such—important though that is to be aware of that danger. But it's also responding to distress in the wider population of young people, and I think it just really underscores this point about building emotional resilience for every child and every school, skilling up every teacher in every school, around a compassionate response to the distress in the young people they might encounter. There's information and support that's available across the board. So, I think it's just such an important point, this. 

Anyone else want to comment on that? Simon. 

Yes, I think Sarah's mentioned it, the most important point, but I think it's also, as schools return, really important to have that non-stigmatising approach. So, if young people are struggling—and some young people will return to a normality relatively quickly, whereas others may well struggle with their experiences during lockdown for a variety of reasons that I'm sure we'll discuss—that approach of it not being medicalised, it being normalised, talking about how you feel, but then also that not being stigmatised, so it's not being minimised in the conversation—. So it's not, 'We've all been through a difficult time, we just need to brush ourselves down and get on with it'. It needs to have that open and honest conversation because, obviously, things like stigma around mental health can start really early with how young people see the adults in their lives react to it. So, it's important to have that balance that doesn't medicalise but also doesn't dismiss the concerns that young people have.

Dawn—or, Kate, did you want to come in? We can't hear you a second. Oh, there we are—that's better. 

Suicide ideation is complex anyway, and if you add to the mix the lockdown and the impact on young people then we really need to be aware of that, that a lot of young people live with thoughts of suicide and it's about how they can manage that at the moment. I think there are surveys out there now that are showing some good things, but what about those young people who are perhaps under the radar, who we're not hearing from? We know that, for example, child and adolescent mental health services referrals are down. What is happening to those young people who would normally be referred through the school system or social services system? So, it's about being mindful of those that really struggle, who are at one end of the spectrum, really, when it comes to mental health. 

That's the key point, isn't it? There is a spectrum of responses to the situation, ranging from the healthy response to being locked down to the very far end and the suicidal thoughts, and so on and so forth. What would be the key messages that you hear as services? What are the key messages that you're hearing from children and young people about the impact of coronavirus on their mental health and well-being?

Shall we go to Steph first, then Kate?

Diolch. Thanks very much. So, very quickly in terms of the key messages that we're hearing, we've already had some references to feelings. In terms of what's been presented to Meic from children and young people—and appreciating that, in that regard, in terms of what comes to the helpline, it's passive, so I wouldn't want to suggest that this is representative—the feelings are, as we've discussed already: loneliness, fear, anxiety, stress, all those things. And those are wrapped up in a whole host of issues that are being presented. So, there are very key messages in terms of concerns about the virus itself in terms of the health aspects and how they might be at risk, or their parents or their family or their loved ones, how they might be affected by the virus itself.

But also, importantly, alongside that are the impacts of the measures as a result that have been put in place to protect them and every one else. So, not going to school, social distancing, being confined in very close quarters. So, it's those kind of psycho-social contributors as well that are interplaying alongside the pandemic itself in terms of the concerns and issues that young people are presenting when they come to us, which will initially be couched in, 'I'm feeling sad', 'I'm feeling angry', 'I'm upset', 'Why, what's happening?', 'I'm arguing with my parents', et cetera, et cetera. So, it's that combination. Those are the key things that are coming through.FootnoteLink 

Kate. 

It's interesting, because I would say, in the first couple of weeks, if anything, our calls went down from the same time last year. It was almost as if people were getting their own house in order, reacting to Maslow's hierarchy of needs, really—you know, making sure there was food in the house and all of those things. And, as time has gone on, again, there have been changes in what we're hearing. So, young people were telling us at the start that some of them felt that they were robbed of being able to do their GCSEs and A-levels—to shine in that respect—and that it was frustrating that all that hard work, they felt, had gone to nothing. So, there were lots of real frustrations about their academic feature. 

What has started to come through now is that they're talking about their feelings that they might be left behind. So, I agree with what other people have been saying earlier about how schools approach this when they do eventually go back—so, making sure that they take on board those feelings of a loss, really, of what they haven't been able to achieve but, yet again, the anxieties that come with feeling that maybe they are falling behind. It's so important. 

We're also hearing about the lack of privacy at home. Certainly, it's more difficult for young people to reach out to get support. We're also hearing that access to services has changed. I think a part of that is to do with young people who live with thoughts of suicide feeling guilty—that they mustn't reach out because they will be a burden to a service that is already overstretched. And then, more recently we're getting more calls that are related to financial difficulties and real problems in relationships within the family—real frustrations coming through very strongly. I would agree with my colleagues that feeling isolated and lonely, in particular, seems to have a very adverse effect on thoughts of suicide. 

Thank you. Dawn. 

My final question, Chair, really, is whether the witnesses could tell us what work they feel is needed to get a clearer understanding of the longer term impact of the pandemic on young people's mental health, particularly something that the Government can start to plan and budget effectively for, for appropriate support to be put into place.

Simon. 

I think that the starting point is something that the committee has talked about on a number of occasions, which is ensuring that the data collection around access to services, referrals, where they're coming from, and having that broken down by protected characteristics as well, in terms of ethnicity and things like that, I think is really important, so that we get an idea of where the pressures are on the system, as well as how those pressures are being coped with at any given time. And I think that is quite a basic starting point to understand. And, really, I don't think we can wait for that to be in place. I think we've got to think about what we can do now to put in place things, if the worst possible situation happens where we do see more people and more young people becoming unwell—do we have the capacity already in the system to deal with that? And I think it's been quite well evidenced, in the work of the committee and others, that there are gaps in that system. I think it's particularly worrying—some of those gaps that continue are around early intervention, below specialist CAMHS, which are probably going to be some of the areas where young people will need some support coming out of this. I think it's quite concerning that, if we do see young people come out of this with some level of distress, where they do need support—as Sarah rightly says, not every young person will need support; they'll have family and friends that they can move on from—but it is quite concerning that maybe some of those services aren't there, and the data around what's happening is probably not in the best possible position for us to be able to say exactly what's going to happen in the coming months.

Okay. Sarah then Steph.

Thank you. I absolutely agree with everything Simon was saying about data collection. And I'd just add a couple of things to that. One of them is about engaging with young people themselves, and potentially using what we already have, so we've got voices from young people, the child facilitators, in various ways, so listen to them. I think that's critical. And the other part of this is just being aware of the very unequal situation of young people. And we've talked about the situation of young people who are not in school, or on the verge of exclusion, or have been excluded. And I think one of the things that we need to be super aware of in our recovery from the situation is just how unequal the impact is on different groups. And I would just urge the committee, in terms of what you think about recommending—schools are looking at those young people on the margins, and the ones who are likely to, or who already have disappeared off the school roll. So, I would just think, be mindful of that, and be hopeful as well. Because we know that suicide is not inevitable—there are things that we can do to help to reduce and prevent it. And there's a lot of evidence around how you engage people effectively. There's not a huge amount of evidence on economic downturns and young people, and I think maybe we need a bit of work to look around that. But, certainly, compassionate responses in school, training teachers, confident approach—feeling that, in a situation where you might feel really powerless, actually you do have some power to listen and to support compassionately, not to stigmatise. So, just some thoughts for ways forward.

Okay. Before I bring Steph and Kate in, I'll take a brief supplementary from Siân. Is it on this, Siân? 

It is, yes. I'm just wondering how much information there is out there—statistical information—about how many people are falling off the radar. You're saying that there are people, but how do we find out how many are falling off the radar, because we're being told that schools are in contact with most of their pupils?

Okay. I think that's a really good point to bring Steph in, to pick up that and the other points that were raised by Dawn, if that's okay, because you're in direct contact, aren't you, with young people?

Sure. Whether I can answer that specific question—I will try and do my best. We certainly know, with regard to the youth and community-based provision, that there are a lot of children and young people who aren't in touch with services, whether that is the community-based provision and/or schools. And I suppose I would link that to a more general point about the whole issue about how a young person is defined. So, a lot of the discussion already has been about school, at school-based age, which is perhaps up to 16 or 18, and we haven't considered, apart from Sarah's comments about young people who've fallen off the radar—. But there are whole swathes of young people for whom life doesn't just stop at the age of 16 or 18 when they leave school. They continue to have ongoing issues around emotional well-being and mental health, the brain development and all the rest of it into their 20s. So, I would be concerned to also consider young people up to the age of 25 and, therefore, most definitely outside of school environments. So, that would be one thing.

In terms of how to gather that data and intelligence, that is for specialists with regard to research who have far more expertise and skill in those areas than I do. All I can say, from my perspective, is that we get a whole load of young people, mostly aged 11 to 25, coming through to us from all over Wales, all different situations and circumstances. Very often what they have in common is that they find it very difficult to talk to a trusted adult, even though they may have many trusted adults around them, whether that's their parents, their families, their GP, or they find it difficult to express themselves, or they find it difficult to look after themselves, or to seek the help that they need and to put that into expression. So, we get the young people who are, effectively, stuck, don't know where to go and don't know how to help themselves or to seek help.

So, with regard to the original question around research, I think, as has already been mentioned, there's a lot of data collection that already goes on, there's a lot of intelligence gathering that goes on. And to add to that, specifically around the impact of the pandemic, we've had the recent joint report now published from the Welsh Government, children's commissioner, Children in Wales and the Welsh Youth Parliament, which is absolutely fascinating, and I think a really, really good piece of work. As a starting point, is that a baseline from which to benchmark, as we go forward? How does that match with general emotional well-being, mental health data and intelligence gathering that already exists? I would like to see much more of that being put in the public domain, being shared as part of a community of interest and practice, so we can actually—all as partners in this together, including young people—be looking at this together and learning from it and coming up with agile new solutions fit for purpose for the twenty-first century.

Thanks, Steph. Kate, and then we are going to have to move on to the next set of questions. 

I'll quickly answer. The drop-off in CAMHS [correction: CAMHS referrals] is telling us something. I know that's not proper research, but that is telling us something. Also, services are available, they are out there, so maybe it's about doing a campaign to remind people that these services are still there, and also a campaign for parents. You know your child—if there's a behaviour change, reach out, don't just wait, because we know the sooner we get in—. And also, nobody's mentioned the school nurse provision. As children go back, they're a good buffer, aren't they, for young people? So, maybe it's doing some work with them as well as teachers and parents, and obviously listening to the voice of the young person—that is crucial in all of this.

Okay. Thank you, Kate. And on that note, I've got a couple of questions now to put on behalf of young people. The committee has been asking young people what questions they'd like us to be asking. So, the first question is: are lots of people dying by suicide? Can you explain the wider impact of lockdown on families? Who'd like to start with that? Sarah.

Okay, great. Really good questions, and in answer to increasing suicides, I think we need to be careful here, because we don't have the data that shows that. So, I don't think that there isn't a significant risk, and that we should be very mindful of the warning signs around. But we need to be very clear that we don't have the data that shows an increase in suicides at the moment. And that links into the next point, which is about the impact of the pandemic on families. I should say that, in terms of what we hear coming through generally at Samaritans, we know that at least a third of our calls are specifically talking about the impact of COVID-19 on the individual and their life, and it's an underlying issue in many more of our calls. We also know that people are, for example, being worried about their mental health; there's ananxiety that's going up, but not necessarily suicidal thoughts. So, we're in an interesting place at the moment, but what we do know is that economic downturns, significant, big economic shocks, have an impact on suicide rates and suicide risk. We know that loneliness, isolation and lack of belonging does as well. So, I think that we need to be very wary, very aware of the risks that there are in the situation that faces us now, but also as we come through the pandemic and see what's on the other side.

Thank you. Kate.

Yes, I would agree with Sarah in all of that. Of course, we don't have any data on that, on suicide, at the moment. What we do hear from young people is that they're struggling with the urge to self-harm in lots of cases, because they can't access those mechanisms that were there—the support mechanisms of friends at school or the other things that they're used to doing to help distract them; all of that has changed. We know that our advisers are finding it more and more challenging to find ways to help people who are struggling with all of this. Again, family frustrations are definitely coming through, and issues of privacy, especially for those young people who share a bedroom with three siblings, for example. There's a lot of literature out there for parents on how to help young people when they're spending a lot of time in their bedroom and things like that, but the reality is that, for many families, there is just nowhere to go, and that is a huge issue. Again, anxiety to do with COVID—most of our calls are COVID-related, to do with anxiety, panic attacks, fear of dying, fear of losing a loved one. All of those things are coming through quite strongly at the moment. 

Okay, thank you. And in relation to self-harm and what you've said, are we seeing—? I mean, I do appreciate, obviously, you're picking that up on the helpline, and it's really helpful to know that. Is there any wider evidence on the impact of this on the numbers of young people self-harming?

Well, to be honest, Lynne, I think that what A&E figures are showing us is that numbers are down, but that doesn't necessarily mean that it's not happening. What it may mean is that it's happening but families are coping with it themselves; maybe they don't want to access services. So, I think that is quite an interesting one and it does make me wonder what's building, really—is this the calm before the storm?

Okay. And in terms of our efforts, then, to prevent suicide, and bearing in mind the challenges that we've discussed about not knowing what the impact is yet on suicide rates, how should we as a committee encourage the Welsh Government to focus their suicide prevention efforts going forward? Kate.

I would say that young people need to know where they can go for help. It's really important. They need to know who they can talk to. Again, it's about making sure that we do talk about suicide, that we don't hide behind that, and that schools and teachers are being supported in that. So, I mean, for me, it's about adequate training for teachers, that they feel knowledgeable and they've got the skills to actually talk to young people about it, but signposting young people is essential as well. We've got to make sure that it's a service that is available and sustainable as well.

Thank you. Sarah, then Simon.

Thank you. Absolutely. I think it's useful just to think back to what would have been useful in this crisis, actually, because it's also a chance to think about prevention and think about the kind of turbulent uncertainty that the world can throw at young people. So, I think that this question of young people learning to name emotions—that kind of whole-school approach to resilience is really, really important. So, I think you can kind of build into that that it's terribly important that young people are seeking help and that they're not stigmatised for doing that, that they're talking. So, encouraging that is critical, and training for teachers and the whole-school community approach to this, aligned with the specialist services that I'm sure Simon will talk about as well. So, there's a real opportunity to really pick up this debate that we've been having for a while about the evidence that really shows that a whole-school approach, that learning about resilience, learning about emotional literacy and understanding the need to seek help is one critical way of identifying those who are more vulnerable as well. So, I think there is a menu of things we really can do.

Thank you. Simon.

Just briefly, it's a classic question that we come back to quite a lot, around how do we support people earlier and how do we ensure that the investment is moved downstream, without disinvesting in more acute services that are needed as well. I think this is the kind of ideal moment, really, to make that decision—to look at what is available further down to support children in that kind of missing middle, which is a complex range of young people as well in terms of their needs. And I think there needs to be some real thought, probably during the next few months, because hopefully, we won't have a second peak; we may well, towards the winter time, but we have this period now to really think this won't be an emergency second time around, we'll know it's coming. A lot of thought is being given now to moving resources into different areas, to build resilience within the services, and within the support mechanisms.

And what I want to say is: that includes within the voluntary sector as well as within the NHS, so it can actually be there to support people, young people. If we do end up in another lockdown period, we can be far more confident of the resilience and robustness of the response.

Okay, thank you. And I've got a final question from a young person, which will take us on neatly into Suzy's questions on the impact on services: 'Today I went to the crisis team. My mental health is getting worse. I have manic depression and my GP had referred me. They turned me away. Why do they leave you feeling worse than when you got there?' Simon, do you want to start on that?

Yes. I mean, that's heartbreaking. In terms of those services, we're being told that services are in place, time and time again, by Welsh Government and NHS Wales; that they are there for people and there to support people. I think, on crisis services for young people, there's quite a bit of work to do around identifying what that model looks like. A lot's been done in terms of thinking about the model for adults. If any young person is attending a service, desperate for help, that service should be there. There's nothing in any guidance or any legislation that has suggested that those services shouldn't be there, but I think it just shows—I know myself and Sarah have met with Welsh Government regularly over the last few weeks—the gap between services being there and sometimes the reality of trying to access those services, and trying to access them then in a way that helps the young person.

We all know you can't do face-to-face and there are challenges around that, but I think it's what we do pick up from certain groups of young people: that they are really struggling, and if a young person is in crisis, they should be met with support and compassion and be helped through that. I think that is deeply worrying that that situation has happened to that young person.

Thank you. Steph?

Just very quickly, to reinforce some of the points that have been made. Unfortunately, that situation that you describe reflects quite a lot of contacts that we do get coming through to Meic, so whether it's about GP, school counselling, child and adolescent mental health services, unfortunately, and probably because of the position that we occupy as the helpline service that we offer, we do get young people commenting an awful lot about the negative responses that they've received, which has inhibited them from seeking further help, and this is certainly a concern. Because it may be for a person for whom, for example, the pandemic and the crisis we're in now, this may have been a trigger, which is the start of a journey, or might just be a one-off episode that, if it isn't dealt with at that early point and met with the compassionate response that's been described already, is likely to drive things underground, internalise things, prevent people from seeking help, until such time as things escalate and erupt into something else that becomes far more problematic and difficult to deal with.

So, unfortunately, I totally kind of get what that young person is saying; we get that a lot. And there is something about needing to make sure that responses are timely and compassionate—that there is no wrong door. Whenever or wherever a child or young person presents themselves it's not, 'Oh, this isn't right for you,' or, 'This is all I can offer. On your way.' That's not good enough. 

Okay, thank you. Suzy.

Thank you. Those are really worrying comments, not least on the back of what Kate said earlier about some people just not wanting to bother the health service in any way, so that demand was down for, you know, kind reasons, I guess. But, it's only a month ago since the health Minister was in front of us and telling us that there was enough capacity in mental health services, and CAMHS in particular, to meet demand. So, I'm trying to work out from my question, about whether that was because it was a month ago a response to that desire not to bother people, or whether it's more a case of people were being pushed back because they were being told, 'You've come to the wrong door.' I don't know if any of you have got any comments on that, because I'm very worried about that statement by the Minister if it's not true.

Simon.

Yes, I think there's certainly—. I think it's about a third of adults and approximately the same of young people who responded to our survey who have said that they don't feel their problem is serious enough to come forward. And there's a real concern that that growth of self-stigma of, 'It's not a big enough problem to bother anybody, and would I get support for it?' I think that's a real concern. We knew that some of these services were under pressure in terms of number of referrals and waiting times—not for all services, but for some of them. And whilst we've been given assurance that those services are in place—and I think young people's services were one of the first ones that we raised with Welsh Government and we were assured that whilst services weren't operating as they used to, they were there and available for young people, but then referrals were dropping off and were quite low. Now, as I understand it—I haven't seen any of the data so I can't say exactly what level the referrals dropped off to or what they look like now, but they've been gradually going up over the weeks I think as people have (1) become more confident that the service may well be there and have got that message, and (2) probably based on, 'Well, I might have been able to cope for three or four weeks on my own, but actually, beyond that period it's getting quite difficult and challenging for me.' So, I think there's a mixture of the two things there.

I mean, I share the concern that, across mental health services, both adult and young people, the drop in referrals seems to indicate, you know, where has that need gone? Where has that demand gone? It's gone behind closed doors, and I think this is why we were sceptical in our evidence that we gave to the committee, just about not knowing exactly what's happening until we start to come out of lockdown, because we don't know. But, what we know is that that demand seems to have certainly reduced, but I don't think any of us believes that that demand has in actual fact reduced. Young people just aren't accessing services and support, and we really need to think through in terms of what happens when there's a growth in confidence that is it safe, maybe, to do that, or that we get to a point where young people really need to be doing that.

Okay. Well, that answers part of my question, but the other part was what about those people who are presenting, and not getting access to services? Which is a point we were discussing on the last question from Lynne. I just can't get these two statements to marry up into an 'everything's all right,' which is what was being suggested.

I've got Kate on this. I'm going to have to make a plea. I mean, I would really love—[Inaudible.] This is my favourite subject in the world, but we're going to have to try and be a bit concise, I'm afraid. 

Okay, my next question is much shorter.

I was just thinking it would be really good if we could just capture some of that data somehow and map it, because we don't know what and where, and it might just be that there's something happening in one part of Wales—I don't know. We need to shine a light on that somehow. 

Suzy.

Yes, I can come back with that in my second question now. This is about young people who have been discharged from in-patient units. We've had the assurances that that only happens when it's clinically appropriate for that to happen. But, is that your experience, or have you had people coming to your attention who have been discharged from in-patient units, but haven't then had the CAMHS pick-up that they would need? 

Simon, did you want to start on this?

Yes, sure. We haven't had that direct experience with young people coming to us with that. The in-patient capacity in Wales in terms of young people isn't very large in terms of the number of in-patient beds either. So, I can't really comment on the experience of young people who have been discharged. We've had the same assurances that you've had about that being appropriate. 

I think that there's probably an issue here around Health Inspectorate Wales in terms of how they are continuing to inspect and visit in-patient facilities, now. Obviously, that had to be suspended initially, but we just want to ensure that the quality is still there and that those young people are also being supported if they do have an issue whilst they are in an in-patient unit. That is being dealt with and being supported through the necessary processes. Apologies, that's not answering your question, Suzy, that's just adding to—

Well, it is, actually. It doesn't seem to be the hugest of issues. Brilliant, thank you.

Just very quickly from me on this. The Minister has said in a letter to me, copied to all AMs, that there's a COVID mental health monitoring group now in Welsh Government. Have there been any discussions from that group fed into the Wales Alliance for Mental Health? Just a 'yes' or 'no' is absolutely fine. Simon?

Yes, we have had some feedback from that group as to what's going on. But, we have been asking for sight of data or sight of what's providing assurance and recovery plans and things like that. So, we have regular meetings with the Welsh Government and NHS Wales, which is valuable.

Thank you. We've got some questions now from Janet Finch-Saunders. Janet.

Thank you. Where mental health services are being delivered online, how effectively are these services able to meet young people's needs for support? What about young people who don't have adequate access to digital technology, or whose additional needs—for example, neurodevelopmental conditions and learning difficulties—may make it more difficult for them to engage with online services?

Okay. Steph?

Hi. Okay, so, from our point of view, again, at Meic, we were set up as a service to deliver helpline and online interventions. So, we occupy a particular sort of space. I think that it's been great to see the very positive responses to developing new ways of working to ensure that young people and children are still reached and have access to service delivery, even if it can't be on a face-to-face basis. So, that's a real positive to come out in terms of that agile, innovative way of working.

I think that some of that may just be temporary during this period, and is a workaround, not ideal option; whereas others might become more longer term and permanent. But, I think that it is important, in all of this, to remember that, from our point of view, as a service that has been developed in that way from quite a while ago, with all of the expertise that we've accumulated over that period of time—. It's really important to remember that pre, during and post COVID, not one size fits all. 

So, it's interesting to hear about the neurodevelopmental needs. We find that, actually, a lot of young people with issues actually find online—particularly instant messaging—a lot easier and better than face to face. So, again, I think that it's important just to remember and hang on to the fact that not one size fits all. So, when moving forward out of lockdown, in terms of recovery and thinking about opportunities for changing things, I certainly think, in terms of service design considerations, we have to remember, first of all, we have to be child and young person focused. We have to start with the individual. They have different personalities, situations, circumstances, risks, vulnerabilities, stages of development that aren't just reflective of their chronological age, so they have to be at the centre of service design considerations when it comes to moving forward, as does a recognition of the reality of the support and interventions required. Some support and interventions simply cannot be delivered online, but a lot of prevention, early intervention, talking therapy—as we've seen, for example, with counselling services—can be. Is that then about offering choice to make it specific and bespoke to the needs of the young person? I think—

Could I just ask—? Sorry to interrupt you there. Could I just ask what sort of numbers have you been working with in the past three months?

So, in terms of our contacts, they average between 400 to 500 a month, with about half of them being through instant message. Instant message contacts usually take significantly longer than telephone, so we can be on the phone to someone for—we try and put a limit on it of up to an hour and a half, two hours. There are all sorts of technical as well as other issues around that kind of platform.

With the onset of COVID, what I would say, as I think has been similar across the board, is that we haven't necessarily seen a huge spike. There was a peak where, over one week or two, it did rise as young people were struggling to understand what was going on. But, in effect, the volume has remained pretty much consistent pre and during COVID. But what I would say, again coming back to, reinforcing, something Sarah said, is I would say about a third of our contacts are COVID related, and I would say that that's probably an underestimate, because it's very child and young person focused. So, if they don't make any reference to anything that's COVID related, it won't get recorded as such, unless there's some exploration about what's contributing or what are the consequences, in which case we can log it. 

The only other thing I just very quickly wanted to say is that I think my one concern in terms of the agility of moving to online alternatives, or as well as, is just the need to be mindful that all the core, key principles that apply to face-to-face services remain the same for the online tech world—so, policies and procedures around safeguarding, protection, child protection, abuse. All these things in terms of protecting the young person, they're still the same, as are the safeguards for staff working one-on-one in the virtual world. The principles remain exactly the same, but the details in terms of what measures you need to put in place—policies, procedures, et cetera—are a bit different.

Okay. We are running very short of time. We're going to run over by 10 minutes, but I'm going to have to appeal for really succinct questions and succinct answers, please. Janet.

Thanks. Given the school closures and that people may feel less able to access GP services, how easy is it for a child or a young person with new needs for mental health support to access appropriate services, and is there a need for better signposting to those services?

Who'd like to start? Simon, then Kate, then.

Yes, I think it's probably very challenging—very, very challenging—particularly if a young person has just developed these or reached a point where they need support. At this point, obviously GP services are available, but understanding your mental health and how you can cope with it and manage it day to day is very challenging for a young person, and they need support, and so do parents and families around that.

The other thing I'd add is that I don't think it's just about signposting, it's about looking at self-referral opportunities, it's looking for—I think the BMA have already expressed concern about how primary care will deal with both physical and mental health issues that are coming out following the lockdown, because of this concern that people aren't accessing services. We probably need to think more creatively about, 'Well, is the GP the only way in which you can access a service or support?' During this period, a lot of voluntary sector services have picked up people. They have been—. As, I guess, Steph and Kate and Sarah have all indicated, we've seen a steady increase in people seeking help and support over the piece. How do we diversify those opportunities for people to seek support? So, it's signposting, but also ensuring that there's a wider range of services commissioned, I think.

Okay. Is that okay, Janet? Oh, Kate, you wanted to come in, didn't you, briefly.

No.

Are you sure? Okay.

Can I just ask, Chair, did you ask the question about the toolkit earlier? I know that you asked about a panel. There's a mental health toolkit launched on 1 June. Will stakeholders such as yourselves be involved in the review and updating of this as time goes by—yes or no?

I'm not sure if anybody knows the answer to that, to be honest. Have there been any discussions with any of the third sector on it? Steph.

Certainly from my point of view, yes, we've been involved and there's been some consultation, and I know that Meic has been flagged up as a go-to within that.

Okay. Thank you. We've got some questions now from Siân Gwenllian. Siân.

Who would like to pick that up, please? Was that your hand there, Kate? Yes. Kate.

Would anyone else like to come in on this? The guidance, Kate, that you referred to in Scotland is due to be published in Wales this week, so we're looking forward to seeing that. Does anybody else want to come in on this, or shall Siân move on to her next question, if nobody else has got any comments on schools reopening? Siân.

Who'd like to come in on this? Sarah.

Thank you. So, I'd go back to some of the things that we were talking about earlier on this one, actually. I think there are a couple of things. We need to think about the teachers and how they are able to respond and proactively encourage, just talking with young people themselves across the whole school community, and their knowledge and understanding about what is there to help them and how they can talk and who they can talk to. I think there's also the specific support for young people who are encountering and struggling with returning—so, all those things.

I think overriding is that we don't have to start from scratch with this; we've already got some really good resources that we can be using, utilising. So, we need good suicide recovery and suicide prevention plans for schools. We've got a good guidance document that has already been issued around how—. So, being aware of those things that exist already. We produced a document about working with compassion for schools, which is all about supporting—teachers supporting each other, teachers responding to distress amongst young people.

And I think the messages around help-seeking are just really important. One of the features of the response to COVID-19—in lots of ways, it's been a very, very hard time and it's getting harder, but there have been some real sparks of hope around how strongly people talk about kindness and compassion, and we need to build on that. So, I think that a really important message in terms of young people returning, and teachers, is that kind of compassionate response that needs to run through everything.

Simon.

Just briefly, obviously, we should be well positioned. We've been talking about having a whole-school approach to mental health now for quite a while. There's a consultation document that's ready to go, so I think that needs to be issued as soon as possible so that we can get that, because there's never been a better case for having a whole-school approach to mental health than we have now, and that being embedded at the heart of the curriculum and at the heart of, culturally, how schools approach things.

I think, just, I guess, as a final point on this, I've just been meeting with my colleague and he used a quote that really resonated with me, saying, 'We're all in the same storm, but we're not in the same boat,' which I think is really important as schools go back. There are going to be young people whose experience of lockdown is going to be quite traumatic and difficult, in terms of those from black and ethnic minority populations, with the increased level of fear, potentially, in those communities of what the virus will do and how it will impact on them. That needs to be recognised within schools, not in a medical way, but recognised. Some children of front-line staff will have had really quite a worrying time period where maybe they're not seeing a parent as often, and schools need to work with parents and really think about—yes, you have something for everyone, but there may well be groups, during this period, that are really impacted, and are impacted in a different way. There needs to be some thought about how those groups of young people are supported appropriately so that they can feel that they are moving forward at the same rate as their peers, but may need extra support.

Thank you. The final question, then, from Jayne Bryant, who's waited very patiently.

Thank you, Chair, and I thought that what Simon's just said is really, really important in terms of black and ethnic minority young people as well, so I was glad you were able to say something on that.

I think Kate touched on it very early on, around some of the financial difficulties that parents are having and the impact then that has on children and young people. We know there's a huge amount of pressure on parents and carers where they're home schooling and juggling all these responsibilities and concerns. Do you think there's been enough attention given to the mental health and well-being needs of parents and carers?

Who'd like to pick this one up? Kate.

I suspect not, actually. In the last couple of weeks we've had a lot of calls from what we call concerned others—it could be parents phoning on behalf of young people—and what's coming through is things like a parent is supporting a young person with mental illness, and how difficult that is, and how strained the relationship has become. While that parent is supporting that young person, they feel completely unsupported themselves. So, it's recognising that. There's been so much with the lockdown; initially, it was fear of dying by COVID, and then, as time's gone on, different things are coming through. But I absolutely believe that we haven't done enough for parents and carers who have been really, in lots of cases, left with that—[Inaudible.]—all of the responsibility, really, and none of the support.

Okay. Anybody else want to make a final comment on that question? No. Okay. Steph—and this will have to be the last comment.

Yes, just very quickly, in terms of what's coming through to us again from parents as well as young people, there seems to be some mirroring going on. So, we've got children and young people saying they don't want to burden, and add to the stresses and worries, of their already-under-pressure parents and families, and likewise we've got parents that are saying they don't want to be sharing and dumping their stress on their children. So, both are coming to Meic, if you like, to seek advice around self-care and efficacy and what they can do to help each other and find their way through. 

Okay. Well, we've come to the end of our time. In fact, we've run over, but thank you so much for sharing your views with us. That has been incredibly useful, and we're really grateful to you for giving us your time this afternoon. As usual, we'll send you a transcript to check for accuracy following the meeting, but thank you all very much again for your time. Thank you. 

Item 6, then, is a motion under Standing Order 17.42 to resolve to exclude the public for item 7. Are Members content? Thank you. 

Can I welcome everyone back to our final evidence session this afternoon on the impact of COVID-19 on the mental and physical health of children and young people? I'm very pleased to welcome our witnesses this afternoon, Dr Kristy Fenton, consultant child and adolescent psychiatrist at Hywel Dda University Health Board and chair of the Royal College of Psychiatrists Wales's faculty of child and adolescent psychiatry: Dr Liz Gregory, consultant psychologist and here today representing applied psychologists in health national specialist advisory group; and Dr Bethan Phillips, highly specialist clinical psychologist at Cardiff and Vale University Health Board and co-chair of the division of clinical psychology in Wales, and representing the British Psychological Society. Thank you, all of you, for attending this afternoon. We do really appreciate your time. We're going to go straight into questions, if that's okay, from Dawn Bowden. 

Thank you, Chair, and thank you, everybody, for coming along this afternoon. Can I start by just asking you about young people? Many of the feelings that they're experiencing at the moment, such as anxiety, sadness and loss, could probably be described as a normal response, a normal healthy response, in fact, to the coronavirus emergency, rather than a mental health problem. Is there a need for clearer messaging about that, to make sure that the right kind of support is available to them?

Who'd like to start? Bethan. Is it all right if I call you Bethan?

Yes, that's fine. Yes, very much so, and I think, in terms of the British Psychological Society, and the children and young people's faculty, we were really keen when coronavirus first came, and the changes were coming, and it looked like schools were closing, to educate the public in terms of what is a normal reaction. So, we actually produced some guidance for parents around talking to children about illness, talking to them in a developmentally appropriate way. So, we use that resource, that guidance, that we put together to share some psychological models and get that out to the public. And that's been cascaded really widely across all sorts of different channels and avenues. I actually received it as a parent from the headteacher of the school that my children go to, so it was amazing, really, to see that coming out.

But, yes, it's really important not to pathologise, because we've all been through a massive change, and it's frightening and it's scary, and that's normal. And what we were encouraging, and what we continue to encourage, is parents to talk and have conversations, at an appropriate level, with their children about what's going on. And I think it's showing them and teaching them useful life skills that uncertainty is around us and we don't always know what's going to happen. Yes, children love routine and they normally know where they're going Monday to Friday, and all that kind of thing. But as they get older, it's important to realise things pop us—yes, we weren't expecting coronavirus, but things do pop up out of the ordinary. So, I think, for lots of children, going through this will help them become more resilient and more able to cope with unusual things. But that's some and not all.

Okay. Kirsty—Kristy, sorry.

I have to say I agree with everything that Bethan has said. But I think we also need to be aware that there will be a small proportion of people—and I know, in the data that came out on Monday from the commissioner's report, the large majority of children reported that they are doing very well. And there is a subset within that—I think it was about 1,000, the number—of children with difficulties, and it would be interesting to see how the data tells us how they are doing, so that we're making sure that we get the right services to the right people. The majority of them, no doubt, will be fine with the support of their parents and peers and teachers, but we also need to be aware that children who've experienced adverse life events, those that are in situations of poverty, domestic violence, may need additional support at that time.

Okay. Liz.

I would agree with what both my colleagues have said. I think what we've been finding, clinically, is that there are two extremes. So, some families who would ordinarily struggle are actually doing better as a result of this—I think they're feeling less pressure, rather than more pressure, and they're having time to consolidate, and be together, and grow together, if you like. And then there are other families who are really, really struggling. So, it's not a one size fits all. But I think, generally, it is a really anxious time, and responding to anxiety and fear by being more cautious, more tentative, is what we all need to be doing. And actually that serves a really positive function, particularly as we ease lockdown, that we do need to be more vigilant and more aware of what's going on around us, and so not to pathologise that, as my colleagues have said.

But it's the spectrum of responses, isn't it, that can be from mild anxiety to quite serious mental health disturbance as a result of this? So, it's just being—that messaging, I suppose, is the key thing. What are the key messages that services are hearing from children and young people about the pandemic, in terms of their mental health and well-being? What are the key messages that you're getting from them?

I've got Liz, then Bethan, then Kristy.

I think, certainly from our observations, lots of children and young people are feeling worried and anxious about health, the health of their relatives who may be vulnerable. That's definitely around. But I think one of the most striking differences, if you like, is that the impact of not going to school on some of our more vulnerable families has actually eased a lot of stress and tension for them. So, I think it's really, really important that we learn from that and that we think about what schools do for children—it's an additional source of stress for them. So, I think there's some learning to be done as a result of that. 

We've had some really interesting feedback from young people, and one comment that really struck me was hearing from a young person that the anxiety that they're feeling—that older people are feeling, sorry—about coronavirus is 'how we feel about climate change'. So, just putting that perspective in that this is affecting different generations differently; that maybe it's providing some insight about that sense of foreboding and worry that children are facing—the kind of bigger picture.

Yes, for different reasons. 

Yes, absolutely.

Bethan. 

What I'm hearing is that lots of families have really developed in terms of their resilience skills, and have coped better than they would expect. If you had set this as a scenario that might happen, I think people would have really panicked. So, lots of colleagues are saying that some families have been hugely resilient and there's been a change in presentation.

In terms of the children I work with in Noah's Ark in the children's hospital, lots of our children are very well, because they're not mixing; they're in a protective immune bubble. So, lots of the children with health conditions who, when they're in school, may  not always have their eye on the ball with their medication or the diabetes or things like that—lots of the children with chronic conditions are actually quite well, because they've been kept at home, which obviously isn't a long-term solution, but it's been interesting as an observation. 

For my colleagues out in the community, obviously, children with learning disabilities and autism and things like that have really struggled with the change and the loss of routine. And lots of those community services and those community support structures that would normally be there to help support them have all either been stopped or they've changed to online video consultations, which don't often work for those children with developmental difficulties or the younger children. 

In CAMHS, they've seen things like children reporting with a loss of routine; sleep has gone out of the window. So, when they're trying to maybe support young people with eating disorders in terms of eating at regular times, they're sleeping until 11, because they haven't got to go to school. So, there are lots of things there. And, in terms of working with children with mood disorders, normally you'd be encouraging them to get out, to get busy, to do things, to see friends and, for teenagers especially, the cut-off from their social networks is something that lots of them have struggled with. So, that's what I've noticed. 

Okay. 

Kristy.  

I think, just in addition to what my colleagues have said, a number of children wanted to put their therapeutic interventions on hold, because school wasn't an issue, and that was the main source of their anxiety and difficulties. But, whereas we're preparing to return children to school, people are starting to bubble up a bit more, and thinking about how we can support them in that return. 

The other area, which has been a more difficult area, is those who are transitioning. So, particularly those who are transitioning from primary to secondary are anxious that they haven't been able to say goodbye to friends, or experienced their leaving assemblies, et cetera, and haven't had an opportunity to those transition days in their secondary school, but also those who are transitioning from A-levels, so going into adulthood, into university. And that's a high-risk area anyway, without COVID.

Sure. 

So, those are a concerning group.  

Liz. 

Can I just add that a fairly consistent observation that we've had is that needs dipped at the beginning, but actually they're rising now? It feels like the nine, 10, 11-week period seemed quite significant, and lockdown fatigue, or a dawning realisation that this wasn't going to go away—there are all sorts of hypotheses about why that might be. But I think, after a fairly early settled period, things are starting to rise in terms of concerns and worries, and that's been pretty consistent across a range of groups of children and young people. 

Sure. 

Can I just say that, certainly, that is echoed in the number of referrals that are now being referred back into specialist CAMHS and people presenting in more of a crisis situation, in comparison to how things were at the beginning of COVID? 

Yes, okay. Thank you for that. My final question, Chair, is: what work do you think is needed to get a clearer understanding of the longer term impact on children and young people? Basically, how the Government can start to plan and budget more effectively for the appropriate support that needs to be in place, as we come out of this period. 

Bethan. 

I think it's all about asking the questions, isn't it? So, the children's commissioner report—it's the first one that I've seen that’s come through. It's more like that. And then also thinking—. Obviously, the information we're presenting today is quite anecdotal and ad-hoc and just quickly asking colleagues and texting them—that kind of thing. But maybe some clearly-thought-out research and some more robust measures to look at measuring things and really getting an understanding of what's gone on. I think it's really important to hear the children and young people's voice in that.

Yes. Kristy.

Certainly, in line with that, Professor Ann John has recently published in The Lancet about having more joined-up access to databases, research databases, and quite a lot of work has been done. So, the universities of Oxford, Reading and Southampton are doing the Co-SPACE—Supporting Parents, Adolescents and Children during Epidemics—and Co-SPYCE—Supporting Parents and Young Children During Epidemics—studies at the moment, which are looking at family responses to coronavirus and how they have coped. So, an investment in longitudinal research is really needed. We need that information now of how people are coping, but you also need to use this as an experience for future planning.

Okay, thank you.

Thank you.

Liz, was that—?

Sorry, Liz.

I just wanted to add that I was talking to colleagues from DECIPHer earlier—they are the Cardiff University research body that undertake the school health research network data, the well-being in school. So, they've got some really good, robust, longitudinal baseline evidence, if you like, about where children were this time last year, and where they might be this year and going into the future. Drawing on that larger, epidemiological study to see what difference COVID has made feels really, really important.

Okay, thank you. I wanted to ask about suicide and self-harm, and whether you could share with the committee your views on the impact the pandemic is having in the short term on levels of suicide and self-harm, but also what you think the longer term impact might be, please. Who'd like to start? Bethan.

This is feedback from my CAMHS colleagues in Cardiff who said that, initially, there was a massive drop in referrals for self-harm and the crisis team, and in terms of presentation at A&E and things like that, but gradually, it's picking up. Actually, they've noticed more boys than usual presenting with self-harm and the crisis team, and they definitely feel it's getting busier, and also that it's getting riskier. So, maybe that children and young people who are struggling with those thoughts and feelings, perhaps because they're at home and under the spotlight of their parents, are maybe then using more extreme measures or extreme methods to act out on some of those thoughts and feelings, and I think that lockdown fatigue. I've got a young person who I've been working with, who did make a suicide attempt two weeks ago. I think it’s that build up of being at home and being out of school. This is a person on the autistic spectrum, just really struggling with everything, and then something else on top, and boom—.

But one thing, I think, with all the changes around COVID and the changes in the hospital, it's not been that joined up or seamless in terms of what happens to these young people and these young children. So, this was someone who has just turned 16, but ended up in the adult A&E and on an adult ward for a week because no-one knew what to do with them and couldn’t get hold of the CAMHS because people are remotely working. So, lots of the logistics around providing that crisis support for young people—. This is one family that I work with. I was disappointed on their behalf. It shouldn't have been like that, because he wasn't allowed a parent with him because there are no visitors. So, he was very frightened. It was just a really, really tricky situation, but I think that's a communication between the ambulance—. There are lots of systems there, which are all stretched and working under different ways at the moment. But I do wonder how many other young people have been let down by some of those systems. He was absolutely scared witless and no parent with him for five nights over in the Heath. That's my experience, first hand.

Okay, Is there anything anybody would like to add on that? No? Kristy.

Just adding, in terms of research, when we're looking at the impacts of increased suicidal rates, perhaps more to an adult population, but thinking about the economic effects of suicide and actually thinking that young people are the core of a system and are very much influenced by their own parental mental health. So, being very aware that we need to, perhaps, be a bit more alert to parents' needs and supports at this time.

Okay, thank you. And one of the things that the committee has been doing is trying to make sure that we put children's voices at the heart of everything we do. So, we've got some questions that children and young people have given us to ask, and I'd like to ask one of those now: 'I know that people are self-harming more due to lack of help from mental health services. What is being done about this?' Who'd like to take that one? Bethan, then Liz.

I think it's tricky, as professionals, we've all had to quickly turn around how we work and how we do what we do and how we're able to offer that. For me, I'd often refer lots to third sector organisations in terms of supporting around self-harm and things and they sort of had to close their doors initially because they were not set up.

So, I appreciate the question from the young person. I think professions are very aware and mindful that, perhaps, they're not able to provide what they could and what they should be doing but it's trying to work out how best to provide what they need in the circumstances that they and we as professionals find ourselves in. I know that in some areas, they're still setting up these online videos. It's having the technology and having the infrastructure to be able to get our skills out there to those young people and also how those young people can share those needs and get in touch with the people they need to support, because ordinarily, perhaps a child might have self-harmed of an evening and a PE teacher might have spotted it or someone at school and they're mixing with people; someone might have noticed, and then the calls go in and the process starts. So, if you've got lots of children and young people maybe self-harming in private, without them sharing that, it's very difficult, as professionals, to be able to help them.

Okay. Liz then Kristy.

Yes, I wanted to reiterate that, from our perspective in services, and actually, our third sector colleagues have kept going, adapted their services and kept going in terms of interventions. The difficulty that we've got is making that public, for children and young people to know. So, I think it's communicating that we're open for business, we're here if you need us, and getting over that barrier, because as Bethan said, usually, services work because there are lots of eyes on children and lots of opportunities to notice change or to ask questions that might not easily come up in the context of the family, or children might not want to bother parents because parents are particularly stressed at the moment.

So, it's been a real struggle to get the message out there and to let children and young people know that we're desperate to help them, we're thinking about them all of the time, and how can we communicate that. I know that, definitely, the children's commissioner's office has done a fantastic job, but I think it's a constant thing and it's about finding the forums that actually tune into where young people are at. But from our perspective, we're here, we want to help, we want to do what we can. We're limited, obviously, by the same limitations everybody's got, but just to get that message out there that we are thinking of them and want to help where we can.

Okay, thank you. Kristy.

Yes, I really wanted to say the same as Liz—to encourage people to try to access the service, because in several areas, the CAMHS services have increased their single point of access facilities. Previously, it was only professionals who could refer in, but because of COVID, in some areas, parents have been able to call in and have a discussion with professionals, and that has meant that they've provided therapeutic intervention. It may not need another appointment, but there has been advice and signposting given at that initial appointment. So, perhaps they haven't needed to come into a specialist service, but they have been signposted, and also the school counsellors have continued to provide a service. So, it's knowing that they're kind of still up and running as well. So, we still want to hear from people.

Okay, thank you. I've got a further question before Suzy comes in linked to this: 'I am meant to be assessed by the mental health nurse regularly, but I've been told that because of COVID, I must wait until it becomes more serious until I can be seen. Why do I have to wait until it becomes more dangerous?' Kristy.

Yes. When COVID first, kind of, came up on the horizon, we had to work in terms of thinking about our staff resources, because we had to plan for staff to be redeployed, and therefore young people were assessed within their clinical teams in terms of a risk rating, and a red, amber or green risk rating was applied, and all young people were contacted to discuss what their current needs were, and to ask them whether they were happy to wait, or did they want to have a telephone service or a video appointment. And we've continued to apply that and ring people periodically to check in with them to see if that kind of rating has changed as time has gone on. So, if they're needing an assessment, and they're within that, kind of, red, amber and some green, to some extent, rating, I know that we're now working with all young people, checking in with them. That is possible to happen.

Okay. Liz.

I would reiterate that. In the health context, because COVID was very much a health responsibility, and we were all—all of health—seen as being a potential resource to be directed at COVID. It was a real struggle, I think, to advocate on behalf of children and young people with mental health—and mental health generally, I think—in that context. And in our services that are either partnership or third sector, they have just carried on as usual, whereas the services located purely within health have been part of that kind of bigger picture, if you like, which has been tricky, and I think that's moved on significantly, particularly as the need for COVID-related services has lessened or not been as big as anticipated. But there was that period at the beginning when working in health meant that you were directed towards COVID unless it was considered life or limb, and that was really hard. And for me as a psychologist, I think we're always arguing that point in health—we're always in that hierarchy of what's more important, and this has really highlighted that, I think.

And do you think—? I mean, that's a worry, isn't it, when we're told that parity between mental and physical health is something that we're meant to be aiming for? That shows how far we've got to go, doesn't it?

I think it does. What I would also say is that COVID felt different to anything I've ever faced in terms of that level of anxiety within health about what we might be facing, so I think it has to be understood in that context as well. But certainly, if we're preparing for a second wave, then I think we will be much clearer in mental health services about this being equally important and that we need to be supporting young people, because the long-term consequences of not doing that poses as much risk as turning our attention elsewhere.

Thank you. Bethan.

In addition to that, I think one thing I notice in working in the hospital—. I mean, it didn't actually come to it, but, in terms of what they were wanting, or thinking about potential redeployment, I think one thing that is important is that they were thinking about the well-being and the psychological first aid and things that we could provide to our colleagues and to the people on the front line. So, lots of our resources have been pulled, initially, into helping support our colleagues who were on the front line and setting up hubs and the havens and those kinds of things. So, lots of the psychological resource was moved into that, initially. And thinking about all the changes going on in the hospital, if you were to walk into the children's hospital now, it looks very different to how it is normally. So, I've been linking up, and I think that's an important thing—even though we work with children and young people, we also work with our colleagues in the health service, and having some time and some space to think about and support them has been important, too. That's something I'd want to share with the young people, as it were: we've not forgotten about them, but we're just trying to use our skills and spread ourselves a little bit thinner, and also thinking, like Kristy said, about the workforce—lots of us are working on reduced capacity because professionals suffer from COVID also.

Okay, thank you. Suzy?

Those are some very interesting answers there, because even though we were talking about the parity between physical and mental services, we've also been told—I think it was two or three meetings ago—that children's services, certainly in terms of needs of their assessments, shouldn't be affected. There are regulations that have come in allowing for some relaxing temporarily of rules regarding adult assessment. We were also told by the Minister about a month ago that there's plenty of, or enough capacity, anyway, in CAMHS and mental health services more generally. And yet, the witnesses we had in the previous session, just less than an hour ago, said that wasn't necessarily the case, or, at least, if the capacity was there, it was either not being used because people weren't coming forward, which we've been discussing, or people were coming forward and being told that they couldn't have any care. Lynne mentioned earlier that awful situation where somebody was told, 'You're not serious enough yet for us to talk to you during the COVID period.' I'm trying to marry up these statements. If there's enough capacity, is that because of lack of demand, or is it that there is demand, it's being turned away and we don't know why? 

Who'd like to—? Liz?

I think there is capacity, and I think definitely that referral rates via our usual routes have meant that that capacity is not being particularly challenged at the moment because referrals have reduced significantly. So, we have a single point of access in our region, where all services for children's emotional well-being and all requests get discussed in one forum, and I think referral rates were down by about 50 per cent. So, there is capacity but the worry is, I think, the usual routes for identifying children's difficulties aren't in place. I think that's where the mismatch comes. And I know certainly from the third sector's perspective that they've set up, or enhanced, a number of helplines. So, my guess is that that model of hearing directly means that they're getting much more of the need—they're much more aware of the need, but the service provision models mean that we're not hearing about that need in quite the same way, particularly because it's usually through other routes; it's usually through teachers, through GPs, and people aren't going to the GP in the same way. You know, we're going around to our doctors and saying, 'Encourage people,' and they're saying, 'Well, they're just not coming.' So, I think that's where the mismatch comes, and certainly we're aware in services that it's not a reflection of the need; it's just a reflection of what we can do given the lockdown at the current time.

Just before I ask you to come in, what about the reverse of that where people are effectively knocking on the wrong doors?

Well, I'd hope that, certainly in our region, the single point of access means that that never happens—that if a request comes in, then every service, every potential service is around the table. And, actually, we have a kind of value within that that there is no wrong door. I don't know that all regions have that, but I think it reinforces the need for it even more—that we've got to have all eyes and ears listening out for children who are struggling. And that's not necessarily the traditional route of going to the GP or the other kind of more common routes that, actually, anybody can spot when a child is needing a bit more additional help. 

Thank you.

Okay. Kristy. 

Thank you. I wanted to say that again yes, the capacity is there, but I wonder if there are limitations in the delivery of an intervention. So, in terms of perhaps our usual way of working not being quite what we would apply for that particular set of symptoms—for example, an exposure therapy, in going out onto the beach or whatever, is limited at the moment. We have telepsychiatry in place in some areas. It hasn't quite rolled out universally yet, and the limiting steps there are lack of IT provision within the infrastructure to be able to do that universally. The research produced by Aneurin Bevan has shown that telemedicine, telepsychiatry has been received really positively, but it isn't a one size fits all. It's quite difficult on some occasions for people to have a private space to talk, or having a family member in on the conversation and giving their opinion when you might want to have something a bit more discreet. So, it's also about how we can give that intervention, if that makes sense. Does that answer your question to some degree? 

Yes. Thank you.

Bethan.

You know, some of the feedback I've had is that, like you said, the capacity is there but not everybody wants to do it over the phone or over the video, or they haven't got the—. I think this is where issues around poverty and deprivation come in; if people haven't got a device, a tablet, an iPad or whatever, it's not the same. So, from what my colleagues in CAMHS are saying, about 30 per cent have said, 'Actually, we don't want the video, we'd rather wait.' So, there are a lot of people out there waiting.

I think, for me in the children's hospital, what's been helpful is that all the families I work with I know, so I've been able to pick up the phone, I've been able to do a video call, and they know me. I think if I was a complete stranger to a young person in distress, that would be really tricky. And you're probably only thinking maybe eight plus. Those under eight—. I tried to do a session with a four-year-old. It just doesn't—. You need to be—. That's when I'm on my hands and knees, I'm playing, I'm doing what I'm trained to do, face to face, and, over video, you can't do that.

I think, as professionals, we've had to very quickly adapt our practice and think about how we can offer our skills and offer our therapies and offer the things that we're trained in, but not all of that works on these sort of platforms. So, I think lots have chosen to wait. I know that, with lots of my families, I check in, I'm ringing, I'm seeing how they're doing, but we're not actually getting into the nitty-gritty of anything because it doesn't feel right or they've got too much going on. The families, like you said, are furloughed or been made redundant. There are lots of stresses. Is this the right time to be thinking about deeper issues like attachments and relationships and things like that, which is normally the kind of thing that we'd consider? So, it's a tricky balance.

Liz, then Kristy. I'm going to have to make a plea to be brief, though, I'm afraid.

I just want to reiterate that, but what I would add is that, for some young people, the virtual platforms have proved a bit more helpful for them and they've said that it's easier to talk about some things because there's a bit of distance, and, for some families, they like not having to tidy up before you come around. It is a very mixed picture. What I'm really excited about is the learning that COVID will bring in terms of flexibility and range of options, and meeting children and families, kind of, more targeted and delivered to what suits them and giving them choice.

Kristy.

I just wanted to add that also there is perhaps more of an expectation with virtual meetings that you're asking parents to be co-therapists, and sometimes that can be helpful in the fact that you're opening communication and bringing them together, and that can help their progress, but, at other times, that can feel like an additional burden for parents. So, that's something that's difficult to judge at times. 

Okay, thank you.

Just very quickly—this is almost a 'yes' or 'no' question, actually—CAMHS in-patient capacity looks like it's probably sufficient and we've had reassurances that no-one is discharged from in-patient services until they've got somewhere else to go. Is that your experience? Is that what's happening on the ground?

I don't have any kind of data on their capacities at the moment, but certainly, anecdotally speaking, as a community psychiatrist, we haven't had difficulty putting people into the in-patient unit. Again, procedures have changed in terms of COVID testing—there's a slight delay in people being admitted and being held on other wards.

What about—? Sorry, carry on.

Where we've had discharges—. So, early in the COVID, we had people who were discharged but were continued to be provided with support by the in-patient service virtually. So, they were working joined up with the community teams to provide virtual assessments, virtual therapy, and continued to jointly manage those young people with the community teams.

Thank you.

Okay, thank you. Have you finished, Suzy?

Yes, that's all from me.

Yes, lovely. We've got some questions now from Janet Finch-Saunders.

[Inaudible.]

We can't hear.

Sorry. Where mental health services are being delivered online, how effectively are these services able to meet young people's needs for support? What about young people who don't have adequate access to digital technology? I know, in my own constituency, some don't even have access to broadband. But, for those with additional needs, neurodevelopment conditions and learning disabilities, it may make it more difficult for them to engage with online services.

Bethan.

Yes, that's something that we've very much noticed. Again, the BPS have produced some guidelines for professionals in terms of thinking about working online and working remotely with children and young people, and thinking about the key things that we need to make sure that are in place and thinking about what works and what doesn't work and what the other options are. It's not perfect. We're doing the best that we can with the facilities and the resources that we and the families have got. Like Liz said, I think working in this way has been a really interesting process to go through, and it's something that I'll hold on to and carry on using as part of my practice, though not the entire. And I think for those groups that you mentioned, those who are more deprived or with learning disabilities, or those with neurodevelopmental disorders, and especially thinking about some of the assessments around autism and neurodevelopmental assessments and cognitive assessments, you can't do those on video platforms; they just don't work that way. So, there's a big chunk of young people and children that is doesn't work for, but I don't think that's for the lack of want of trying on our part; it's partly to do with them and their presentation, and their abilities and the nature of working on online platforms.

Okay. Siân, have you got a supplementary on this? Go on, then, briefly.

Can anyone comment on that? Bethan.

I'm not aware of that personally. I know lots of schools are trying their best to get devices out to young people. I think when engaging with the family, I'll check, discuss and talk through, because it tends to be a phone conversation first, beforehand, to see what they've got. But in terms of the children that are under my care, that's not available to me; it might be in other areas.

Liz.

I think that is an issue. I'm not sure of any particular examples where we've not managed to work with the family, but I think, certainly, what our health board have tried to do is be really, really flexible about the usual protocols around the general data protection regulation and things. So, for example: for some families, FaceTime; for other families, Zoom; for other families, Attend Anywhere; for other families, Teams. It has been a scramble and it's been really, really difficult, but I think families doing their bit to find what they can, and us doing our bit to find what we can—it's about marrying that up. But huge learning for the future in terms of the basic things that we need if we're going to (a) face something like this again, but (b), I think, just in terms of giving families choice.

Okay. Thank you. Kristy.

In addition to what Liz said, in terms of flexibility and choice, and then, combined with those check-in calls that we do, there is an opportunity for people to come in and have a face-to-face session or be seen, perhaps, somewhere else where they're more comfortable—obviously social distancing rules are applied and use of PPE is required. But we are giving that opportunity for young people to have those sessions, as needed.

Okay. Thank you. Very quickly, Liz, because I've got to go back to Janet.

I just wanted to add that we're adding new things to our armoury all the time, and now we've got a term that's called 'garden visits'. So, you go and you visit the family in the garden to do that at a distance. So, I think we're all desperate to meet the need as creatively as we can, and it's tricky, obviously, because of the limitations that this brings.

Thank you. Janet, briefly. We can't hear you.

That's weird.

There we are, we can now. It's okay.

Okay. Given the school closures and many people may feel less able to access GP services, how easy is it for a child or a young person with new needs for mental health support to access appropriate services, and is there a need for better signposting to these services?

Liz.

I think we've said a bit about this. I think we've got to use every platform to publicise as much as possible. What I will say, and I think this is a huge benefit, really, is that we have been much more proactive about getting good-quality information out to families. So, there are all sorts of resources online that are being circulated, and families are feeding back that that's really, really helpful. It's just one level, of course, and it's not the more intensive bespoke interventions. But I think everybody has upped their game in terms of getting information out there.

Kristy.

As I said earlier, our single-point-of-access services have increased their remit of who they will expect referrals from and be able to share those resources, and, as Liz said, being quite inventive in what we're providing from that first appointment, from that first initial telephone consultation about where this person's needs are best met. So, those services have expanded. I know, within my health board, we've gone to a six-day service, and in another health board, they're now accepting phone calls from parents.

Excellent.

Can I just ask about the young person's mental health toolkit that was launched on 1 June this year? Will stakeholders be involved in the review or updating of this as time goes on?

Liz.

I'd like to think so. It was great that our health board was involved in giving resources to that. I think what's absolutely vital, and I don't think we're there yet, is how much it is being used and how useful it is. It's only as useful as it is in terms of the feedback that we get from children and young people. So, yes, I'd like to see that, definitely.

Bethan, then Kristy, and you're going to have to be really brief, I'm afraid.

Liz has said what I would have said. It's fine.

Kristy.

I just wanted to say I think when I last looked at it, it had something like 20,000 hits or something already. It was quite a lot and maybe that's an exaggeration, but I was really impressed with how many people had already looked at it.

Okay. The Welsh Government's announced £4 million extra for support for children's mental health because of COVID, and this committee has had strong views about how extra resources should be spent in line with the reforms we're pressing. In particular, we were concerned about counselling being provided for much younger children through the schools. Are you content with the plans? Is there any message that you'd like to place on record about how that money can be best spent, because it's a significant sum? Liz.

I think, just going back to the opening question, that we don't want to pathologise this experience. This is a very unusual set of circumstances, and our responses are very, very normal. So, for me, I think it's any investment that actually builds on existing relationships that children and young people already have, so time for teachers to reconnect at a personal level, to really tune into each child's unique circumstances, because everybody has experienced COVID in a very different way, and I think for some families that's been about loss and bereavement, for others, it's been about financial concerns, for others, it's been a pressure-cooker of tension because of mental health issues or domestic abuse issues, and for others, it's been a really safe bubble, and a really positive time for them. So, I think the idea of one size fits all is something that we really need to avoid. But what we know helps most in terms of recovering from trauma is pre-existing relationships and reconnecting, and doing that in a safe, calm, supportive and gentle way, and recognising that you can't expect children to be learning until they're feeling safe and secure in their environment. So, prioritising that is something that I feel really strongly about.

Bethan, very briefly.

Yes, I think from a professional standpoint, we welcome the investment. In terms of using school counsellors at primary school age, it really needs to be thought out in terms of who the people are that are appointed, the training, the experience and the expertise that they have. As Liz would say, I think, as professionals and psychologists, we'd be looking at the whole system and things like that around the child, and I wonder whether some more creative things could be done with that money in terms of, maybe, training up the people that they've already got the relationships with, or just increasing that emotional well-being curriculum within the class, or one of the things I'm going to suggest to the headteacher of my school when she opens is thinking about that emotional literacy support assistants programme and, actually, whether they could roll that out for all the children. Because there can be no harm in doing things like emotional literacy, mindfulness and some of those more basic psychological skills that would be really helpful to everybody. I think children don't need a counsellor to do that, but they need someone who they feel trust in, that they feel they can confide in if they need to, but someone they can have open conversations with about how they feel, and acknowledging that different feelings are okay. I think that's a hard thing for children to do, and they need that trust and that relationship with people to be able to do that. I'm not always sure that bringing in a school counsellor is the best way to do that from a psychology perspective.

Thank you. Siân.

Liz, then Bethan.

I'm really pleased with the way Welsh Government have managed this. I think it has given time for schools to prepare, and it's also given a clear message that this is about checking in and reconnecting rather than any sort of pressure to catch up on work, or other interpretations that might be around. I also really like the idea that it's potentially for all children, not just one targeted year group. So, I think it's been managed really well. I think it needs to be done carefully and slowly and safely, and teachers need to feel in control of that, and to feel that their perspective is valued in that, and that they know their populations. I think some element of choice as well—families will vote with their feet, I guess, but definitely, from our perspective, it's an opportunity for particularly our most vulnerable children to have a place outside of school where they can go and be, and play and relax and reconnect with people who know them well, feels really, really timely.

Bethan.

Yes, I'd reiterate what Liz says, although I think for me personally, working in a children's hospital, all the children that I work with are shielding, so they won't be able to go back to school. There is a population who won't be going back on the twenty-ninth, and won't be going back for some time, and I have concerns about these children, who already feel different because they've got mostly a chronic health condition, and what that will mean. I think teachers are going to be very stretched to accommodate going back and what that means, as well as thinking of those who are still at home and shielding and trying to provide support and resources for those. So, I'm going to have an eye on that and make sure that those children aren't lost in this. And the repercussions there—because I've got people asking me, 'Well, can the siblings go back?', or 'I'm a teacher, I'm a parent, but my child is shielding—'. So, I think for the general population, going back across all the year groups, staggered as it will be—and it will look very different—will be positive.

As far as it's well managed—I think some schools have managed COVID very well, and others not so well, but if it's managed well, I think for the majority it will work, but thinking about children with health needs and disabilities and learning disabilities, and that population who aren't able to go back, there are still lots of questions about what that will look like, and whether they can even go back in September. For older children in that category, if parents are coming off furlough and are happy to go back to work—so I've got parents of teenagers that I work with with cystic fibrosis saying, 'Oh, I don't know that I want to leave him at home, but I've got to go back to work, and he's 14—how are we going to manage that?' So, there will be pockets of children who will still be struggling, even once the schools go back, because they're not back, and I think it's worth keeping them on the radar also.

Kristy.

In addition to what's already been said, I think it's worth keeping in mind teachers' views as well, because we know that a teacher who is not anxious and able to be psychologically minded and open with their class is going to be much more available, and a positive role model to them, than a teacher who is anxious and worried about contracting illness, or not being able to keep the children apart. So, I think we really need to make sure that support is there for teachers.

I think, just slightly different to Liz's feelings about the all the year groups going back at once, of course the majority are keen to go back to school, and are going to reconnect with their peers, and that's really healthy. But there will be a proportion, and I'm coming from a specialist CAMHS perspective, that are going to struggle with anxiety going back to school, and I wondered resource-wise whether—. I think the concern from CAMHS is: what will the influx be? What's that going to look like? What will demand be? And perhaps if we'd had a staggered response in terms of year groups going back to school, we may have been able to judge that a bit better. From the children's commissioner's report—I've just got it in front of me—it's the year 6 pupils that are really feeling that need to be back in school and do those good vibes and appropriate endings that are going to set them up for that transition. So, I did wonder, with the whole school all going back—there's going to be reduced capacity for year 6s to be in school perhaps as much as they would have been if they'd been the first year to go back. Those are just my thoughts.

Okay. Siân.